Single Source/Sole Source Justification Form
(Page 1 of 2)
Complete this form for general equipment and service requisitions with a value greater than $5,000 (for all
funds) where competition may be restricted. Completing this form does not guarantee that the proposed
vendor will be selected. The Hospital Purchasing Department may require additional information. It is the
requisitioner’s responsibility to provide all the required information and documentation indicated on
this form.
Please return this completed form with requisition, attachment cover sheet and any additional back-up to:
Hospital Purchasing, Purchasing and Distribution Center (PDC)
Ordering Department Account #
Requisition #
Ordering Department Name
Vendor Name
A: Explanation for Single/Sole Source
Select one or more of the following statements (check the box) to support why the requisition attached and
noted above should be a single/sole source purchase. ANY selection requires explanation in the
additional space provided.
1.
Items sold through manufacturer only; no other comparable unit available.
2.
Used or demonstration equipment available at a lower-than-new cost.
3.
Must match existing piece of equipment. Available only from the same source of original
equipment.
4.
Upgrade to existing software. Available only from the producer of this software who sells on a
direct basis only.
5.
Repair/Maintenance service requires expertise in operations on unit. Necessary parts unavailable
from any source except original equipment manufacturer or their designated servicing dealer.
6.
Service(s) provided by the vendor are unique and therefore competitive bids are not applicable.
7.
Other reason.
Explanation for section (A) is required for ANY selected statement. Information provided might
include research performed or subject matter expertise detailed to justify the use of this particular vendor
and their product. This must clearly indicate why the proposed vendor is the ONLY vendor that will meet
your requirements.
Establishment of the Reasonableness of the Price
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Select one or more of the following statements (check the box) to indicate why you believe the accepted
non-competitive price was fair and reasonable. ANY selection requires explanation in the additional
space provided.
1.
The price is equal to or lower than the Premier Inc., group purchasing price list or GSA (federal)
contract price list. (Contract price list must be provided.)
2.
The quoted prices minus the vendor’s discounts are lower than prices available to the general
public and reflect substantial savings. Must state dollars or percentage here
. Explain the
dollar calculation below. Explain how general public prices were determined.
3.
The quoted prices compare favorably to market prices, or to previous prices obtained and found to
be fair and reasonable, which were paid for the same or similar items on:
(date)
, (PO)
, (Bid)
.
4.
The vendor has provided copies of invoices to other customers showing our price to be equal to or
lower than the invoiced price. (Invoice copies must be provided.)
5.
Other reason.
Explanation for section (B) is required for ANY selected statement. Information provided might
include a catalog price page, pricing for similar products or other price comparison information gathered to
justify price reasonableness.
Please attach any additional justification information that would support the above explanations.
I certify that to the best of my knowledge I have investigated and found that the above reasons and
explanations justify this requisition as a single/sole source purchase, and that price reasonableness is
adequately confirmed. I am the individual who has gathered and provided this detailed information and any
further questions regarding these details can be directed to my attention.
Signature:
Date:
Print Name:
Title:
E-mail address:
Phone:
**************************************************************************************
To be completed by Purchasing Department
Justification is appropriate.
Justification appears inappropriate. Agent has contacted the department representative and advised the
status of the order. Explanation is attached.
Agent’s signature ________________________________ Date
Director’s signature ______________________________ Date _____________________ rev. 08/29/2003